The touchstone of good residential/ group home care

The touchstone of good
residential/ group home care
• The struggle for congruence in service of the best
interests of children
• But all programs think they are acting in the best
interests of the children in care, when in fact many
are not, or at least not consistently
• Congruence means that there is consistency,
reciprocity and coherence within and across all
levels of agency functioning
Levels of Group Home Operation
•
•
•
•
•
Extra-agency
Management/Leadership
Supervision and Clinical
Carework/Teamwork
Child and Family
Basic psycho-social processes
• Creating an extra-familial living environment
– the prime task of managers
• Responding to pain and pain-based
behaviour – the key challenge for careworkers
• Developing a sense of normality – the basic
need for young people in care
All positive changes can be traced
to 11 interactional dynamics
•
•
•
•
•
listening and responding with respect;
communicating a framework for
understanding;
building rapport and relationship;
establishing structure, routine and
expectations;
inspiring commitment;
Interactional Dynamics (cont’d)
•
•
•
•
•
•
offering emotional and developmental
support;
challenging thinking and action;
sharing power and decision-making;
respecting personal space and time;
discovering and uncovering potential; and
providing resources.
The Framework Matrix for Understanding
Group Home Life and Work
k) Providing resources
j) Discovering & uncovering potential
i) Respecting personal space & time
h) Sharing power & decision-making
Interactional g) Challenging
thinking & action
Dynamics
f) Offering emotional & developmental support
e) Inspiring commitment
d) Establishing structure, routine & expectations
c) Building rapport & relationship
b) Communicating a framework for understanding
a) Listening & responding with respect
Levels of
Group
Home
Operation
Extra-agency
5
Management
4
Supervision
3
Carework
2
& Teamwork
Youth
and Family
RECIPROCITY
1
I
Creating
an extrafamilial
living
environment
II
III
Responding Developing a
to pain and
sense of
pain-based
normality
behaviour
Basic
Psychosocial
Processes
CONSISTENCY
COHERENCE
Core Theme: CONGRUENCE IN SERVICE OF THE CHILDREN’S BEST INTERESTS
Moving from “last resort” to positive
option in the system of care
• Placing workers need to accept that well-functioning group
care is positive for the right young people, at the right time
• There needs to be a move away from a mechanical formula
for placement that leads to multiple foster home
“breakdowns” before a residential placement
• Child welfare systems need to invest in developing and
maintaining well-functioning group care
• Workers need to carefully assess the level of care,
supervision and intensity required by youth
The challenge of decision rules
For example:
• All children have a right to live in a family (except
those who can’t)
• Try (all) less intrusive services before more intrusive
alternatives (but less intrusive for whom?)
• Place a child in residential care only as a last resort
(which may mean years of misplacements and pain)
• Every child has a right to permanency and stability
(but what do we do to ready them for such a
place?)
• Others?
We are at an exciting time in the evolution of
our understanding of why some young people
struggle with the challenges of everyday life…
and the role quality residential care for young
people can play in helping these young people
to turn around and learn to self-regulate.
Therapeutic residential care is the term being
used internationally for trauma-informed and
therapeutic relationship-based approaches
A recent development is the convergence of the
emerging field of neuro-biology and child and
youth care
Especially the work of Bruce Perry (MD, PhD)
Brain research is now demonstrating that:
• Early childhood traumas alter the development of
neural pathways in the brain;
• but thanks to neuroplasticity, consistent, nurturing
caregiving over the course of everyday life can
help to create new pathways;
• through creating a sense of safety, human
connections and “scaffolding” for self-regulation.
Dr. Perry’s research has demonstrated the
importance of therapeutic relationships in
healing the effects of childhood trauma
“We learned that some of the most therapeutic
experiences do not take place in “therapy”, but
in naturally occurring healthy relationships… “
(p.70)
“People, not programs, change people.” (p. 80)
[From: The Boy Who was Raised as a Dog, by Bruce Perry and
Maia Szalavitz, (2006) New York: Basic Books]
There is growing international evidence that
implementing strong therapeutic residential care
models is having a positive impact on the quality of
care provided and the child outcomes being achieved.
Strong models target the whole residential agency
(and preferably the child protection system) to
implement a principle-based approach that truly
serves the best interests of children.
An effective system needs to be congruent within and
across all levels
So, what is the evidence for its effectiveness?
• The criteria for “evidence-based practice” are
based on the medical drug-trial model, and
require “randomized control trials” (RCTs) which
are expensive, challenging and raise ethical
issues to do in residential care.
• However, recent non-RCT evaluations of
therapeutic models in the State of Victoria
(Australia), Northern Ireland and the USA
(Cornell University) have shown positive and
promising results, and findings from even more
rigorous studies will be available in the near
future.
From TRC Evaluation
(Verso Consulting, State of Victoria, Australia, 2011)
Significant improvements in placement stability
Children and young people placed in a TRC have experienced far greater
stability compared to their previous experience.
Significant Improvements to the quality of relationships and contact
with family
The children and young people in TRC have experienced and sustained
significant improvements to the quality of contact with their family
during their period in TRC.
Sustained and significant improvements to the quality of contact with
their residential carers over time in the TRC pilots
Children and young people in the TRC pilots are developing and
sustaining secure nurturing, attachment-promoting relationships with
residential carers in the TRC Pilots.
Increased community connection
Children and young people in the TRC Pilots were more likely to engage in
community activities or have a part time job than young people in general
residential care.
Significant improvements in sense of Self
Children and young people in the TRC have experienced and sustained significant
improvements in their sense of self, indicating improved mental health.
Increased healthy lifestyles and reduced risk taking
Children and young people in the TRC experienced a reduction in risk taking
which was evident over time in reduced episodes of negative police involvement
(although not immediate), police charges and secure welfare admissions.
Enhanced mental and emotional health
Across the SDQ and HoNOSCA measures, the children and young people in the
TRC experienced improvements and significant reductions in the mental health
symptom severity.
The development and implementation of therapeutic
residential care is a movement towards congruence
across an entire agency and, ideally, the whole child
welfare/protection system.
To be effective, every person in an agency/system needs
to be:
• knowledgeable about therapeutic principles, values
and practice methods;
• working consistently in alignment with therapeutic
principles and values, and
• supported in an ongoing way (‘scaffolding’) to put
them into practice.
• It takes an agency about 3 years to make the initial
transition, but the residents notice and respond to the
change right away
Residential
care is not
rocket
science,
It’s far more
complex than
that!
References
Anglin, J.P. (2002). Pain, Normality and the Struggle for Congruence: Reinterpreting
Residential Care for Children and Youth. Binghamton, NY: Haworth
Anglin, J.P. (2012). The process of implementing the CARE program model. Paper
presented at EUSARF/CELCIS Looking After Children Conference, September 6, Glasgow,
Scotland.
Holden, M.J. (2009). Children and residential experiences: Creating conditions for change.
Arlington, VA: Child Welfare League of America.
Holden, M.J., Anglin, J.P., Nunno, M.A. & Izzo, C.V. (2014) Engaging the total therapeutic
residential care program in a process of quality improvement: Learning from the CARE
model. In Whittaker, J.K, del Valle, J. F. & Holmes, L. (Eds.) (2014) Therapeutic Residential
care for Children and Youth: Developing Evidence-Based International Practice. London:
Jessica Kingsley Press.
Kahn, W.A. (2005). Holding fast: The struggle to create resilient caregiving organizations.
New York: Brunner-Routledge.
Lee, B.R. & Barth, R.P. (2011). Defining group care programs: An index of reporting
standards .Child and Youth Care Forum, 40 (4), 253-266.
Li, J. & Julian, M.M. (2012). Developmental relationships as the active ingredient: A unifying
working hypothesis. American Journal of Orthopsychiatry, 82 (2) 157-166.